Example of a Written Root Cause Analysis

Root Cause Analysis Definition

Root cause analysis (hereafter known as RCA) is a project management methodology used to identify the source of any issues or problems experienced in any process or product. The core idea behind RCA is that ongoing problems are best solved by eliminating the root problem, instead of applying temporary solutions that fail to resolve recurring issues.

Example: Customer Jane Doe receives goods from Manufacturer Smith. These goods are found to be damaged, as they were shipped in packaging trays that allowed the product to move in the cartons during transport. Manufacturer Smith decides to add cardboard dividers between each tray to prevent the product movement in transit. While this is an adequate solution, it does not address the root problem. Why were the goods able to move? The correct solution is to redesign the tray in a way that ensures that each item is fixed securely.This eliminates the necessity for additional packaging material, assigning warehouse locations, adding a

new item to inventory and all associated tasks.

Where is RCA used?

RCA is used in many areas but especially in evaluating issues dealing with Health and Safety, production areas, process manufacturing, technical failure analysis and operations management. While each area has differing methods, a logical process flow applies to all

A Simple RCA Process

The RCA Process

Define the problem. The first stage is of course recognizing that a problem exists and defining it accurately. Did you receive a failure report? What type of problem is it? Is it a customer complaint?

Analyze the issue.Who reported the problem? If identified internally, it can be handled without involving customers. However, if a customer identifies an issue, it introduces many more tasks. In the example above, Manufacturer Smith could have identified the issues internally but the Quality Team or Internal Auditor had failed to simulate transport conditions. Unfortunately the problem has now reached their customer Jane Doe, and Manufacturer Smith will now have to absorb the costs associated with a returned shipment and product replacement. If Jane Doe wishes, she can also request a full technical analysis and problem resolution, making a customer complaint. Customer complaints typically follow a modular 5 or 8 step resolution process involving sign-off from all affected departments. Analyze the problem found and how it impacts on business objectives, indicate which departments are involved, the cost implications to fix the problem and estimate the expected time for completion. Update necessary to satisfy sensitive Quality associates: In this example the blame is placed on the Quality team. While it is true that the Quality team has some responsibility, the root cause is down to the design of the packaging tray(whether internally designed or externally provided) or perhaps the supplier made modifications without informing Manufacturer Smith.

How can it be fixed? Customer Jane Doe is not happy and wants an immediate solution. Using available expertise, outline all possible remedies, time-lines involved and ways of regaining customer satisfaction. Can Manufacturer Smith afford to implement new designs on packaging? Does Jane Doe order sufficient quantities to justify the expense involved? Is the courier responsible due to poor handling practices?

Can you prevent future errors? Manufacturer Smith has gathered all their information and now believes the problem is solved.

Implement the solution. Manufacturer Smith implements the solution and informs Customer Jane Doe that the problem is now resolved, apologizes for any inconvenience and assures her that product quality is their core focus, etc.

Ongoing Monitoring. Since my example involves a manufacturing environment, Manufacturer Smith must ensure that all process documentation is updated to reflect a process change. This can include but is not limited to Production Visual Aids, Shipping Audit Criteria, and any other inline process such as Final Audit, Inspection or related processes. All involved staff (including production operators) must be informed of this change.

The above process steps refer to what is commonly known as cause mapping, and can be portrayed in a number of visual formats, such as "The Fishbone" or Ishikawa diagram which is used as part of Six Sigma implementation. Flowcharts, PowerPoint presentations and other visual tools are also acceptable.

Common Root Causes

Materials: The example used in this article illustrates a material issue where a design solution is required. Material can also be changed by suppliers without notification, resulting in standard compliance issues under WEEE, ROHS, The Sony Green Partner Standard or any number of environmental standards. Materials may cause adverse affects under certain conditions, are health and safety concerns highlighted?

Equipment: Equipment issues can arise because of improper calibration, ineffective preventative maintenance or outdated equipment. In cases where test/process equipment is used; wrong program selection, programmed incorrectly, drifting tolerance levels, contamination of contact points, wear and tear and of course, catastrophic failure where equipment requires replacement. Equipment may have been the cause of an employee injury.

Location: This category includes poorly designed workspace areas and handling practices as well as health and safety concerns, such as location of fire exits, evacuation and security procedures.

Personnel: Human error whether accidental or deliberate, is one of the hardest areas to control, since regardless of supervision or written working procedures there all always those who fail to meet their contractual obligations.

Management: If Management does not have the desire to strive for excellence, it is unlikely that RCA solutions will be implemented in a timely manner. Reasons for refusal to co-operate with RCA findings generally stem from budgetary constraints, or from a reluctance to change from their own time-honored methods. Not all managers are willing to embrace modern ideas, with some actively resisting change.

Lack of Document Control Procedures: If processes carried out bear little similarity to the corresponding documented procedures, then staff training and departmental organization needs to improve. This is a common reason for failing ISO 9000. If a Process or Engineering change process is not used, then effective company communication is compromised.

Conclusion:

Root cause analysis is essential in a modern business and is part of every Project Manager's toolkit. In conjunction with regular auditing, FMEA and other process monitoring activities, it is possible with experience to actually highlight potential problem areas before they jeopardize your business.